Chronic Pain and Functional Outcome 3 years After Total Knee Arthroplasty and Perioperative Dexamethasone: A Follow-Up of the Randomized, Clinical DEX-2-TKA Trial

The effect of adding dexamethasone to adductor block and IPACK block on acute postoperative, rebound, and chronic pain following knee arthroplasty-1-year follow-up

The analgesic efficacy of nerve blocks depends on the duration of local anesthetics, whose effects can be extended with adjuvant drugs. This prospective interventional study aimed to assess the impact of adding dexamethasone to levobupivacaine on the postoperative analgesic efficacy of the adductor canal block (ACB) and IPACK block after knee arthroplasty (TKA), as well as the incidence of rebound and chronic postsurgical pain. One year after TKA, 80 patients were analyzed (dexamethasone vs. control group). Opioid analgesics were administered to 10% of patients in the dexamethasone group and 50% of patients in the control group (χ 2 = 13.393, p < 0.001), with no difference in opioid dosage (p = 0.368) during the first 24 h postoperatively. Rebound pain was observed in 5% of patients in the dexamethasone group and 30% in the control group (χ 2 = 7.013, p = 0.008). Chronic postsurgical pain 1 year after TKA was found in 5% of patients in the control group, without significant differences between the groups. Adding dexamethasone to the local anesthetic for ACB and IPACK blocks, along with a non-opioid scheduling strategy, enhances postoperative pain management, reduces opioid consumption, and helps decrease the occurrence of rebound pain and chronic postsurgical pain 1 year after TKA.

Intraoperative dexamethasone and chronic postsurgical pain: a propensity score-matched analysis of a large trial

BACKGROUND

Dexamethasone has been shown to reduce acute pain after surgery, but there is uncertainty as to its effects on chronic postsurgical pain (CPSP). We hypothesised that in patients undergoing major noncardiac surgery, a single intraoperative dose of dexamethasone increases the incidence of CPSP.

METHODS

We devised a propensity score-matched analysis of the ENIGMA-II trial CPSP dataset, aiming to compare the incidence of CPSP in patients who had received dexamethasone or not 12 months after major noncardiac surgery. The primary outcome was the incidence of CPSP. We used propensity score matching and inverse probability weighting to balance baseline variables to estimate the average marginal effect of dexamethasone on patient outcomes, accounting for confounding to estimate the average treatment effect on those treated with dexamethasone.

RESULTS

We analysed 2999 patients, of whom 116 of 973 (11.9%) receiving dexamethasone reported CPSP, and 380 of 2026 (18.8%) not receiving dexamethasone reported CPSP, unadjusted odds ratio 0.76 (95% confidence interval 0.78-1.00), P=0.052. After propensity score matching, CPSP occurred in 116 of 973 patients (12.2%) receiving dexamethasone and 380 of 2026 patients (13.8%) not receiving dexamethasone, adjusted risk ratio 0.88 (95% confidence interval 0.61-1.27), P=0.493. There was no difference between groups in quality of life or pain interference with daily activities, but 'least pain' (P=0.033) and 'pain right now' (P=0.034) were higher in the dexamethasone group.

CONCLUSIONS

Dexamethasone does not increase the risk of chronic postsurgical pain after major noncardiac surgery.

CLINICAL TRIAL REGISTRATION

Open Science Framework Registration DOI https://doi.org/10.17605/OSF.IO/ZDVB5.